Primary Care Coding Alert

Question: A patient with hyperlipidemia and type 2 diabetes came to our office for an annual preventive exam. Both conditions were stable at the time of the visit; however, our provider ordered a lipid panel and an A1C to check the status of both conditions. As the labs were not diagnostic but preventive, can we still submit a claim for the tests? And do we need a modifier to do that?

Arizona Subscriber

Answer: Yes, although the tests in this case are not preventive, since the patient is already known to have the diseases in question. If your physician ordered tests such as 80061 (Lipid panel...) and 83036 (Hemoglobin; glycosylated (A1C)), you would document E78- (Disorders of lipoprotein metabolism and other lipidemias) and E11- (Type 2 diabetes mellitus) as the primary diagnoses for the labs, rather than Z13 - (Encounter for screening for other diseases and disorders), because screening is the testing for disease or disease precursors in asymptomatic individuals, andthis individual is already known to have hyperlipidemia and type 2 diabetes.

Had the patient been asymptomatic (i.e. not previously diagnosed), then you can submit a claim for the same procedures with Z13.1 (Encounter for screening for diabetes mellitus) appended to a blood glucose test, such as 82945 (Glucose, body fluid, other than blood), 82947 (Glucose; quantitative, blood (except reagent strip)), or 82948 (Glucose; blood, reagent strip); and Z13220 (Encounter for screening for lipoid disorders) appended to 80061.

In this situation, you would also append modifier 33 (Preventive service) to each CPT^® code. The modifier 33 indicates that the primary purpose of the service is the delivery of an evidence-based service that has been given a U.S. Preventive Services Task Force A (high net benefit) or B (moderate to substantial benefit) rating. Modifier 33 is typically appended to codes that can be either preventive or diagnostic, but, when used, indicates to the payer that the tests are being used preventively, rather than to monitor the patient's condition to see it is being managed effectively.

Coding caution: Modifier 33 should not be appended to claims submitted to Medicare or Medicaid. Such claims are regarded as containing "incomplete or invalid information." As such, they are regarded as "unprocessable," and will be met with Medicare Outpatient Adjudication (MOA) code MA130.